Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures

Obstructive sleep apnea and obesity: A review of epidemiology, pathophysiology and the effect of weight-loss treatments

Despite the commonly-accepted paradigm that patients with obstructive sleep apnea (OSA) also invariably have obesity, OSA prevalence extends beyond obesity. This necessitates a reevaluation of screening strategies, biomarkers of increased OSA risk, and heightened awareness among healthcare providers about the array of OSA treatments for diverse adult populations. While obesity contributes importantly to OSA pathogenesis, there is substantial evidence that non-anatomical factors also play a crucial role, especially in patients who do not have obesity. In recent years, notwithstanding the recognition of diverse contributors to OSA pathogenesis, research has frequently focused on weight reduction to address OSA. Insights from past experiences with bariatric surgery in OSA serve as a lens to anticipate potential outcomes of emerging anti-obesity pharmacotherapies. Pharmacological alternatives, particularly incretin agonists, exhibit promise in weight reduction and OSA improvement, but encounter obstacles such as potential side effects and high costs. With this comprehensive narrative review, we delve into the complex epidemiological and pathophysiological connections between OSA and obesity. Additionally, we emphasize the importance of a multifaceted approach to OSA treatment, recognizing that while weight management is crucial, there is a need for comprehensive strategies that go beyond traditional weight-centric perspectives.

Bariatric surgery is as safe as other common operations: an analysis of the ACS-NSQIP

BACKGROUND

Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Nonetheless, some primary care physicians (PCPs) and surgeons from other specialties are reluctant to refer patients for MBS due to safety concerns.

OBJECTIVES

To compare the outcomes of patients who underwent MBS with those who underwent other common operations.

SETTING

American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP).

METHODS

Patients who underwent laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), classified as MBS, were compared to nine frequently performed procedures including hip arthroplasty and laparoscopic cholecystectomy, appendectomy, colectomy, hysterectomy, and hernia repairs, among others. A multivariable logistic regression was constructed to compare outcomes including readmission, reoperation, extended length of stay (ELOS) (>75th percentile or ≥3 days) and mortality.

RESULTS

A total of 1.6 million patients were included, with 11.1% undergoing MBS. The odds of readmission were marginally lower in the cholecystectomy (adjusted odds ratio [aOR] = .88, 95% confidence interval (CI) [.85, .90]) and appendectomy (aOR = .88, 95% CI [.85, .90]) cohorts. Similarly, odds of ELOS were among the lowest, surpassed only by same-day procedures such as cholecystectomies and appendectomies. The MBS group had significantly low odds of mortality, comparable to safe anatomical procedures such as hernia repairs. Infectious and thrombotic complications were exceedingly rare and amongst the lowest after MBS.

CONCLUSIONS

MBS demonstrates a remarkably promising safety profile and compares favorably to other common procedures in the short-term. PCPs and surgeons from other specialties can confidently refer patients for these low-risk, lifesaving operations.

Bariatric surgery efficacy in patients with mood disorders

BACKGROUND

Mood disorders are comorbid in patients with obesity and found in approximately 22.0% to 54.8% of patients who are eligible for bariatric surgery. Given the unclear effect of mood disorders on bariatric surgery outcomes, we aimed this study to assess the impact of mood disorders index bariatric surgery weight loss outcomes.

METHODS

A retrospective study institutional database of index bariatric surgery patients at University Hospitals Cleveland Medical Center between 2016 and 2018. The primary outcome of body mass index was followed over a 4-year period. The secondary outcomes measured were mortality and suicide rates. Mood disorders defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, included depressive and bipolar disorders obtained from electronic medical records International Classification of Diseases, Tenth Revision, coding.

RESULTS

A total of 790 patients underwent bariatric surgery between 2016 and 2018. Of these, 15 patients were excluded due to death in the postoperative period or insufficient weight loss data, and a total of 775 patients (620 women and 155 men) were included. Two hundred and ninety-five (38.1%) had an electronic medical record mood disorder diagnosis before surgery, while 480 (61.9%) did not. Both groups had a significant decrease in postoperative body mass index; however, there was no significant difference in the body mass index change between the mood disorder group (mean = 37.63, standard deviation = 9.88) and the control group (mean = 38.72, standard deviation = 9.54; t[294] = 1.40; P = .1634).

CONCLUSION

Patients with mood disorders are as successful with weight loss after index bariatric surgery as those without mood disorders. There was no significant difference in mortality rates between the mood disorder group and the control group. Hence, mood disorders should not be prohibitive for weight loss surgery.

Moving toward targeted eating disorder care for transgender, non-binary, and gender expansive patients in the United States

OBJECTIVE

Literature suggests that transgender, non-binary, and/or gender expansive (TNG) people are more likely than cisgender peers to experience eating disorders (EDs) and engage in dangerous weight control behaviors. TNG individuals with EDs are dramatically higher risk for self-harm behaviors, suicidal ideation, and suicidal behaviors than cisgender peers with EDs or TNG peers without EDs, and often engage in ED symptoms/behaviors to alleviate gender dysphoria. Yet, no treatment paradigms have yet been adapted for TNG-specific ED care. This qualitative study aims to identify stakeholder needs from such care to inform future clinical interventions.

METHODS

We elicited patient (n = 12) and mental health clinician (n = 9) stakeholder needs and preferences regarding TNG-specific ED care. Semi-structured interview guides informed by the Consolidated Framework for Implementation Research (CFIR) and a behavioral insights framework, EAST, were developed to ensure uniform inclusion and sequencing of topics and allow for valid comparison across interviews. Using a rapid analysis procedure, we produced a descriptive analysis for each group identifying challenges of and opportunities in providing ED care for TNG adults.

RESULTS

Stakeholders expressed needs and preferences for TNG-specific treatment including that it be: (1) TNG-affirming, weight-inclusive, trauma-informed, and anti-racist; (2) delivered by an interdisciplinary team, including gender-affirming care clinicians; (3) focused on parsing gender dysphoria from other body image concerns, building distress tolerance, and working toward gender euphoria (rather than body acceptance).

DISCUSSION

Future work is needed exploring ED care delivery models that integrate gender-affirming care services with mental health care. Such models may improve TNG access to ED treatment and recovery.

PUBLIC SIGNIFICANCE

Transgender, non-binary, and/or gender expansive (TNG) experience disproportionately high rates of eating disorders and have unique barriers to accessing care. In individual interviews, TNG adults with eating disorders and mental health clinicians who provide psychotherapy for eating disorders voiced desire for greater availability of TNG-affirming, weight-inclusive eating disorder care, integrated with other gender-affirming care services. This informs future research developing eating disorder care for TNG individuals.

ASMBS statement on metabolic and bariatric surgery for beneficiaries of Centers for Medicare and Medicaid Services with a review of the literature

This position statement is issued by the American Society for Metabolic and Bariatric. Surgery in response to inquiries made to the Society by patients, physicians, Society members, hospitals, health insurance payors, the media, and others regarding the access and outcomes of metabolic and bariatric surgery for beneficiaries of Centers for Medicare and Medicaid Services. This position statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement is not intended to be and should not be construed as stating or establishing a local, regional, or national standard of care. This statement will be revised in the future as additional evidence becomes available.

Safety and effectiveness of metabolic surgery in older Japanese patients

Aim

According to the current guidelines in Japan, the upper age limit for bariatric and metabolic surgery is 65 y. This study aimed to examine the appropriateness of this upper age limit.

Methods

Using the database maintained by the Japanese Society for Treatment of Obesity, we conducted an analysis of patients in two age groups: those aged <65 y and those aged ≥65 y. Our analysis focused on postoperative weight loss, improvement in comorbidities, and frequency of perioperative complications.

Results

A total of 2885 patients aged <65 y (mean, 43.9 ± 9.5 y) with a preoperative body mass index of 42.4 ± 8.1 kg/m2, while 56 aged ≥65 y (mean, 67.3 ± 3.2 y; maximum, 78 y) with a preoperative body mass index of 40.5 ± 6.6 kg/m2. Patients aged ≥65 y had a higher rate of dyslipidemia and hypertension. The rates of reoperation, surgical complications, and postoperative complications did not differ between the age groups. Both groups achieved significant weight loss postoperatively, and no differences in the improvement of comorbidities were noted. After adjusting the covariate balance via propensity score matching, no age-related differences in perioperative and postoperative complications were observed.

Conclusion

Metabolic surgery is safe and effective for older patients with clinically severe obesity. Weight loss was less in patients aged ≥65 y, but the percentage of total weight loss did not differ between the groups.

LAPAROSCOPIC AND LAPAROTOMY BARIATRIC SURGERY IN A PUBLIC HOSPITAL IN BRAZIL: ARE THERE DIFFERENCES IN COSTS AND COMPLICATIONS?

BACKGROUND

Despite its increasing popularity, laparoscopy is not the option for bariatric surgeries performed in the Brazilian public health system.

AIMS

To compare laparotomy and laparoscopic access in bariatric surgery, considering aspects such as morbidity, mortality, costs, and length of stay.

METHODS

The study included 80 patients who were randomly assigned to perform a Roux-en-Y gastric bypass. They were equally divided in two groups, laparoscopic and laparotomy. The results obtained in the postoperative period were evaluated and compared according to the Ministry of Health protocol, and later, in their outpatient returns.

RESULTS

The surgical time was similar in both groups (p=0.240). The costs of laparoscopic surgery proved to be higher, mainly due to staplers and staples. The patients included in the laparotomy group presented higher rates of severe complications, such as incisional hernia (p<0.001). Costs related to social security and management of postoperative complications were higher in the open surgery group (R$ 1,876.00 vs R$ 34,268.91).

CONCLUSIONS

The costs related to social security and treatment of complications were substantially lower in laparoscopic access when compared to laparotomy. However, considering the operative procedure itself, the laparotomy remained cheaper. Finally, the length of stay, the rate of complications, and return to labor had more favorable results in the laparoscopic route.

Predicting serious complications following bariatric surgery in geriatric patients: development of the GeriBari scoring tool using the MBSAQIP database

BACKGROUND

Geriatric patients have a greater risk of complications after bariatric surgery. The objective of this study was to develop a tool to predict serious complications in geriatric patients after minimally invasive bariatric surgery.

OBJECTIVES

To develop a predictive model, GeriBari, for serious complications in geriatric patients after bariatric surgery.

SETTING

Multiple accredited bariatric surgery centers in the United States and Canada.

METHODS

This was a retrospective cohort study of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, which collects 30-day bariatric surgery outcomes from 868 accredited centers. Geriatric patients defined as those ≥65 years old who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were included. Characteristics associated with serious complications were identified using univariate and multivariable analyses. A predictive model, GeriBari, was derived using a forward selection algorithm from operative years 2015, 2017, and 2019. GeriBari's robustness was tested against a validation cohort of subjects from operative years 2016 and 2018.

RESULTS

A total of 40,199 geriatric patients underwent LRYGB (27.7%) or LSG (72.3%). Overall, 1866 (4.6%) experienced a complication, which included bleeding (1.6%), reoperation (1.6%), reintervention (1.3%), unplanned intubation (.4%), and pneumonia (.4%). Mortality was higher in the geriatric patients than that in younger patients (.27% versus .08%). GeriBari consists of 12 factors that predicted serious complications and stratified individuals into high- (>6%) and low-risk (<6%) groups. This tool accurately predicted events in the validation cohort with sensitivity of 46.0% and specificity of 100%.

CONCLUSIONS

GeriBari enables preoperative risk stratification for 30-day serious complications in geriatric patients undergoing bariatric surgery. Stratifying low- and high-risk geriatric patients for adverse events allows for informed clinical decision-making prior to bariatric surgery.

Safety and efficacy of roux-en-y gastric bypass in older aged patients

INTRODUCTION

laparoscopic Roux-en-Y Gastric Bypass (LRYGB) has been a revolutionary intervention for weight loss with reduction of up to 60-70% of excess body weight. However, these outcomes are not as well validated at the extremes of age, where the safety of the intervention still has some caveats. The aim of this study is to assess the efficacy and safety of primary LRYGB among different age groups.

METHODS

the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for patients who underwent primary LRYGB from January 2014 to December 2017 at a single institution. Four groups were created and compared by dividing our sample by age quartiles. The primary outcome was percent excess weight loss (%EWL) at 1 year. Additional operative outcomes and complications were also compared across groups.

RESULTS

a total of 1013 patients underwent non-revisional LRYGB during the study period. Mean %EWL at one year was 55%. When compared between quartiles, there was a statistically significant difference in %EWL: 1st 62%, 2nd 57%, 3rd 54% and 4th 47% (p=0.010). The differences in the secondary outcomes between age groups did not demonstrate statistical significance.

CONCLUSIONS

though patients in the fourth age quartile (range) did not demonstrate a statistically significant increase in adverse outcomes, they did lose less weight compared to other cohorts. The %EWL at one year after RYGB varied by age in our cohort. Goals after bariatric surgery should be individualized as weight loss is less robust with aging.

Outcomes of Endoscopic Sleeve Gastroplasty in the Elder Population

Purpose

With the aging of the population and the epidemic spread of obesity, the frequency of older individuals with obesity is steadily growing. To date, no data evaluating the use of endoscopic sleeve gastroplasty (ESG) in the elderly have been published. In this case series, we evaluate the short- and medium-term outcomes of ESG in patients with obesity aged 65 years and older.

Materials and Methods

A retrospective analysis was done on a prospective database; patients aged 65 years and older were included in our analysis. EWL%, TBWL%, the Bariatric Analysis and Reporting Outcome System (BAROS) questionnaire, and the presence of comorbidities were assessed.

Results

Eighteen patients aged 65 years and older underwent ESG between November 2017 and July 2021. The median age was 67 years and the mean baseline BMI was 41.2 kg/m². After ESG, the median TBWL% was 15.1%, 15.5%, and 15.5% at 6, 12, and 24 months, while the median %EWL was 39%, 37%, and 41% at 6, 12, and 24 months, respectively. The median BAROS score was 3.0, 3.4, and 2.5 at 6, 12, and 24 months, respectively. Six out of twelve patients with hypertension and 3/4 diabetic patients reduced or removed their medications within 12 months following ESG. Two out of six patients with OSA stopped therapy with CPAP. No adverse events were recorded.

Conclusion

According to our experience, ESG is a promising therapeutic option for elder individuals with obesity who fail non-invasive methods, and who refuse or are deemed not suitable for bariatric surgery because of age and comorbidities.

Graphical abstract

Five-Year Analysis of the MBSAQIP Database: Are We Getting Better?

BACKGROUND

The MBSAQIP has been used to evaluate risk and create risk models. Previous studies have determined what complications matter most.

STUDY DESIGN

This study was a registry-based analysis of patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between January 1, 2015, and December 31, 2019, at centers participating in MBSAQIP. Cases were identified using Current Procedural Terminology. Patients less than 18 years old were excluded. A chi-square test was used to assess differences in the prevalence of complications and effects across years. Using a multivariable Poisson regression model with a link log and robust estimation, prevalence ratio estimates and 95% CI were obtained.

RESULTS

A total of 690,770 observations met the inclusion criteria. Mean (SD) age was 44.5 (±12.0) years, and mean (SD) BMI was 45.2 kg/m2 (±7.9). SG cases accounted for 73.45% of all observations. There was a significant relative reduction in readmissions, end-organ dysfunction, and all-cause mortality from 2015 to 2019 in the SG subgroup. There were also noticeable reductions in 30-day readmission, ICU admission, and end-organ dysfunction in the RYGB subgroup. For complications, bleeding, postoperative pneumonia, and stroke were significantly decreased in the RYGB subgroup, but only bleeding was significantly decreased in the SG subgroup during the 5-year study period.

CONCLUSIONS

There has been a continuous improvement in several (but not all) outcomes through the years that the MBSAQIP has been collecting data. Different outcomes were reduced between the SG and RYGB subgroups, and the decrease in all-cause mortality was only noted in the SG subgroup.

Is Sleeve Gastrectomy as Effective in Older Patients as in Younger Patients? A Comparative Analysis of Weight Loss, Related Comorbidities, and Medication Requirements

Background

Bariatric surgery in the older population has been the subject of ongoing debate but several studies have recently demonstrated its short-term advantages in this age group. It is not yet clear, however, whether these benefits are long-lasting.

Methods

We retrospectively analyzed patients with morbid obesity who underwent laparoscopy sleeve gastrectomy (LSG). These patients were divided into two groups: those above 60 years of age (older group) and those of 60 years or under (younger group). Variables evaluated included demographics and anthropometrics data, comorbidities, and daily medication requirements.

Results

Two hundred fifty-two patients underwent LSG, 57 in the older group and 195 in the younger group. Outcomes related to weight loss in the older subjects were modest compared to those in the younger population (older group %EWL 41.6 vs younger group %EWL 51.1, p < 0.05, older group %TWL 24.9% vs younger group %TWL 25.2%, p < 0.05). During follow-up, both older and younger patients showed an improvement in all the comorbidities: hypertension (older 82.5% vs 38.1%, younger 52.6% vs 29.2%, p < 0.05), type 2 diabetes mellitus (older 38.6% vs 27.3%, 34.9% vs 23.9%, p < 0.05), hyperlipidemia (older 75.4% vs 42.9%, younger 35.9% vs 21.1%, p < 0.05), and OSAHS (older 57.9% vs 30%, younger 40.4% vs 7.1%, p < 0.05). The average number of daily medications used to manage comorbidities decreased in both groups.

Conclusion

LSG in older patients is effective in terms of weight loss, improvement of comorbidities, and lower daily medication requirements up to 5 years of follow-up.

Graphical abstract

Safety of Bariatric Surgery in Obese Patients With Hypertrophic Cardiomyopathy

Obesity is an independent risk factor for heart failure in patients with hypertrophic cardiomyopathy (HC). In this study, we examined national trends and early outcomes of bariatric surgery for obesity in patients with HC. Using the weighted discharge data from the National Inpatient Sample, we identified adult patients with HC who underwent elective bariatric surgery for obesity between 2011 and 2017. A total of 443 obese patients with HC were identified, and 42% (n = 185) had obstructive HC. The annual number of patients increased from 18 in 2011 to 130 in 2017. Overall, the median (interquartile range) age was 50 (43 to 57) years, and 85 patients (19%) were 60 years or older. Approximately 20% (n = 90) of the patients had heart failure at the time of operation. Atrial fibrillation was present in 83 patients (19%), and 22% (n = 95) of the cohort had a pacemaker or automatic cardiac defibrillator implanted before the operation. Laparoscopic sleeve gastrectomy (72%, n = 318) and laparoscopic Roux-en-Y gastric bypass (25%, n = 110) were the most commonly performed bariatric procedures. Overall, patients stayed in the hospital for a median (interquartile range) of 2 (1 to 2) days. During the hospital stay, there were no deaths, myocardial infarctions, or documented episodes of thromboembolism. In conclusion, bariatric surgery in patients with HC is performed more frequently in recent years and is safe and associated with few perioperative complications. Because of the impact of obesity on long-term survival, clinicians should strongly consider bariatric surgery for obese HC patients who do not respond to conservative weight loss measures.

Segurança e eficácia do bypas gástrico em Y de Roux em pacientes idosos

RESUMO Introdução: o Bypass Gástrico Laparoscópico em Y de Roux (LRYGB) tem sido uma intervenção revolucionária para perda de peso com redução de até 60-70% do excesso de peso corporal. No entanto, esses resultados não são tão bem validados nos extremos de idade, onde a segurança da intervenção ainda possui algumas ressalvas. O objetivo deste estudo é avaliar a eficácia e segurança do LRYGB entre diferentes faixas etárias. Métodos: O banco de dados do Programa de Acreditação e Melhoria da Qualidade da Cirurgia Metabólica e Bariátrica (MBSAQIP) foi consultado para pacientes submetidos a LRYGB de janeiro de 2014 a dezembro de 2017 em uma única instituição. Quatro grupos foram criados e comparados dividindo a amostra por quartis de idade. O desfecho primário foi perda percentual de excesso de peso (%EWL) em 1 ano. Resultados: 1013 pacientes foram submetidos a LRYGB durante o período do estudo. A média de %EWL em um ano foi de 55%. Quando comparados entre os quartis, houve diferença significante no %EWL: 1º 62%, 2º 57%, 3º 54%, e 4º 47% (p=0,010). As diferenças nos desfechos secundários entre as faixas etárias não demonstraram significância estatística. Conclusões: embora os pacientes no quarto quartil de idade não tenham demonstrado um aumento estatisticamente significativo nos resultados adversos, eles perderam menos peso em comparação com outras coortes. O %EWL um ano após RYGB variou de acordo com a idade em nossa coorte. Os objetivos após a cirurgia bariátrica devem ser individualizados, pois a perda de peso é menos robusta com o envelhecimento.

Surgical Treatment of Obesity. Special Mention to Roux-en-Y Gastric Bypass and Vertical Gastrectomy

INTRODUCTION

The prevalence of obesity has increased exponentially in recent decades, being one of the diseases that most affects global health. It is a chronic disease associated with multiple comorbidities, which lead to a decrease in life expectancy and quality of life. It requires a multidisciplinary approach by a specialized medical team. Obesity can be treated with conservative or with surgical treatments that will depend on the characteristics of the patient.

OBJECTIVE/METHODOLOGY

The referenced surgery can be performed using different surgical techniques that are analyzed in the present work through an exhaustive narrative bibliographic review in the PubMed and Cochrane databases, as well as in UpToDate.

RESULTS

Currently, those most used are restrictive techniques, specifically vertical gastrectomy and mixed techniques, with gastric bypass being the "gold standard".

CONCLUSIONS

In order to choose one technique or another, the characteristics of each patient and the experience of the surgical team must be taken into account.

A Qualitative Study of the System-level Barriers to Bariatric Surgery Within the Veterans Health Administration

OBJECTIVE

To characterize system-level barriers to bariatric surgery from the perspectives of Veterans with severe obesity and obesity care providers.

SUMMARY OF BACKGROUND DATA

Bariatric surgery is the most effective weight loss option for Veterans with severe obesity, but fewer than 0.1% of Veterans with severe obesity undergo it. Addressing low utilization of bariatric surgery and weight management services is a priority for the veterans health administration.

METHODS

We conducted semi-structured interviews with Veterans with severe obesity who were referred for or underwent bariatric surgery, and providers who delivered care to veterans with severe obesity, including bariatric surgeons, primary care providers, registered dietitians, and health psychologists. We asked study participants to describe their experiences with the bariatric surgery delivery process in the VA system. All interviews were audio-recorded and transcribed. Four coders iteratively developed a codebook and used conventional content analysis to identify relevant systems or "contextual" barriers within Andersen Behavioral Model of Health Services Use.

RESULTS

Seventy-three semi-structured interviews with veterans (n = 33) and providers (n = 40) throughout the veterans health administration system were completed. More than three-fourths of Veterans were male, whereas nearly three-fourths of the providers were female. Eight themes were mapped onto Andersen model as barriers to bariatric surgery: poor care coordination, lack of bariatric surgery guidelines, limited primary care providers and referring provider knowledge about bariatric surgery, long travel distances, delayed referrals, limited access to healthy foods, difficulties meetings preoperative requirements, and lack of provider availability and/or time.

CONCLUSIONS

Addressing system-level barriers by improving coordination of care and standardizing some aspects of bariatric surgery care may improve access to evidence-based severe obesity care within VA.

Rates, Risks, and Time to Fracture in Patients Undergoing Laparoscopic Vertical Sleeve Gastrectomy versus Roux-en-Y Gastric Bypass

Objective

To assess the rates, risks, and time to fracture in patients undergoing laparoscopic vertical sleeve gastrectomy (VSG) versus those undergoing Roux-en-Y gastric bypass (RYGB).

Summary Background Data

Metabolic and bariatric surgery has been implicated in significant bone loss and may increase fracture risk. Preoperative patient characteristics that might impact fracture risk and the time to fractures have not been established. Furthermore, the patient characteristics that might impact fracture risk and the time to fractures by surgical approach are unknown.

Methods

This population-based retrospective cohort analysis used Humana claims data from January 1, 2007 to March 31, 2017, and included 4073 patients undergoing laparoscopic RYGB and VSG as a first surgical intervention for weight loss. The primary outcomes were the incidence of fractures (Humeral, Radial or Ulnar, Pelvic, Hip, and Vertebral) within 48 months after laparoscopic VSG versus RYGB and days to these fractures.

Results

An analysis of total fractures (odds ratio [OR] 0.53; 95% confidence interval [CI], 0.38-0.73), vertebral fractures (OR 0.61; 95% CI, 0.38-0.99), hip fractures (OR 0.36; 95% CI, 0.15-0.84), and humeral fractures (OR 0.44; 95% CI, 0.22-0.90) demonstrated a reduction in fracture risk in patients undergoing VSG versus RYGB. Furthermore, postmenopausal status was independently associated with increased odds of total fractures and hip fractures (OR 2.18; 95% CI, 1.06-4.50; OR 5.83; 95% CI, 1.16-29.27; respectively). Likewise, osteoporosis at the time of surgery was associated with increased odds of total fractures (OR 1.61; 95% CI, 1.09-2.37), vertebral fractures (OR 2.01; 95% CI, 1.19-3.39), and hip fractures (OR 2.38; 95% CI, 1.19-4.77). Except for a significantly decreased odds of vertebral fractures in osteoporotic patients undergoing VSG versus RYGB (OR 0.41; 95% CI, 0.18-0.95), osteoporotic or postmenopausal status at the time of surgery was not found to increase odds of fracture depending on surgical intervention. However, time to fracture (total) and for all site-specific fractures, except for pelvic fractures, was significantly reduced in postmenopausal women undergoing RYGB versus VSG. Time to fracture (total) and for all site-specific fractures except pelvic and radial or ulnar fractures was significantly reduced in osteoporotic patients undergoing RYGB versus VSG.

Conclusions and Relevance

Though bariatric surgery is associated with several health-related benefits, increased fracture risk is an important factor to discuss with patients undergoing bariatric surgery. Bariatric surgery strategy, RYGB versus VSG, carries a differential risk of fracture, with RYGB carrying a higher risk of fracture and decreased time to fracture. Furthermore, patients who are postmenopausal or osteoporotic at the time of surgery carry an increased risk of total fractures, independent of bariatric surgery strategy. Being mindful of patient-specific fracture risk after bariatric surgery may help anticipate, identify, and prevent fractures.

Association Between Physician Part-time Clinical Work and Patient Outcomes

IMPORTANCE

Despite the growing number of physicians who reduce clinical time owing to research, administrative work, and family responsibilities, the quality of care provided by these physicians remains unclear.

OBJECTIVE

To examine the association between the number of days worked clinically per year by physicians and patient mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis was completed on a 20% random sample of Medicare fee-for-service beneficiaries 65 years and older who were admitted to the hospital with an emergency medical condition and treated by a hospitalist in 2011 through 2016. Because hospitalists typically work in shifts, hospitalists' patients are plausibly quasirandomized to hospitalists based on the hospitalists' work schedules (natural experiment). The associations between hospitalists' number of days worked clinically per year and 30-day patient mortality and readmission rates were examined, adjusting for patient and physician characteristics and hospital fixed effects (effectively comparing physicians within the same hospital). Data analysis was conducted from July 1, 2020, to July 2, 2021.

EXPOSURES

Physicians' number of days worked clinically per year.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day patient mortality, and the secondary outcome was 30-day patient readmission.

RESULTS

Among 392 797 hospitalizations of patients treated by 19 170 hospitalists (7482 female [39.0%], 11 688 male [61.0%]; mean [SD] age, 41.1 [8.8] years), patients treated by physicians with more days worked clinically exhibited lower mortality. Adjusted 30-day mortality rates were 10.5% (reference), 10.0% (adjusted risk difference [aRD], -0.5%; 95% CI, -0.8% to -0.2%; P = .002), 9.5% (aRD, -0.9%; 95% CI, -1.2% to -0.6%; P < .001), and 9.6% (aRD, -0.9%; 95% CI, -1.2% to -0.6%; P < .001) for physicians in the first (bottom), second, third, and fourth (top) quartile of days worked clinically, respectively. Readmission rates were not associated with the numbers of days a physician worked clinically (adjusted 30-day readmissions for physicians in the bottom quartile of days worked clinically per year vs those in the top quartile, 15.3% vs 15.2%; aRD, -0.1%; 95% CI, -0.5% to 0.3%; P = .61).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, hospitalized Medicare patients treated by physicians who worked more clinical days had lower 30-day mortality. Given that physicians with reduced clinical time must often balance clinical and nonclinical obligations, improved support by institutions may be necessary to maintain the clinical performance of these physicians.

Gastrojejunostomy in Roux-En-Y Gastric Bypass for Morbid Obesity: Linear Stapler Length Does Not Affect Mid-term Outcomes

BACKGROUND

The purpose of this study was to compare whether different linear stapler lengths used to form the gastrojejunostomy during laparoscopic Roux-En-Y gastric bypass affects mid-term weight loss outcomes.

MATERIALS AND METHODS

A retrospective single center analysis was performed. Surgical technique was identical other than either a 35 or 45 mm linear stapler being used to form the gastrojejunostomy. Multivariate regression was used to assess the relationship between the different stapler lengths and weight loss outcomes 2 years following surgery.

RESULTS

Of the 97 patients identified, 67 (69.1%) were included in the study. There were 30 patients in the 35 mm group and 37 in the 45 mm group. The groups were comparable in terms of basic demographic data and preoperative weight characteristics. There was no significant difference in weight loss outcomes 2 years following surgery when comparing between the different linear stapler lengths.

CONCLUSION

Thirty-five versus 45 mm linear stapler lengths does not affect mid-term weight loss outcomes.

Long-Term Weight Loss, Metabolic Outcomes, and Quality of Life at 10 Years After Roux-en-Y Gastric Bypass Are Independent of Patients' Age at Baseline

BACKGROUND

Conflicting data have been published for bariatric surgery in older patients, with no long-term large-scale studies available. Our aim was to provide long-term (> 10 years) results on weight loss, metabolic outcomes, and quality of life in a large homogenous series of Roux-en-Y gastric bypass (RYGB) patients, according to age at baseline.

PATIENTS AND METHODS

All consecutive patients who underwent primary RYGB between 1999 and 2007, and therefore eligible for 10-year follow-up, were retrospectively analyzed. According to their age at baseline, they were divided into three groups: A (< 40 years), B (40-54 years), and C (≥ 55 years). Categorical variables were compared with the χ² test and continuous variables with ANOVA.

RESULTS

Our series consisted of 820 patients, with a 10-year follow-up of 80.6%. Although group C (11% of all patients) had significantly more comorbidities at baseline, there was no difference in postoperative morbidity and mortality between groups. Weight loss was significantly less for group C patients up to the 7th postoperative year, but no difference remained thereafter. 10-year %total weight loss was 32.2, 32.9, and 32.3 respectively in groups A, B, and C. After 10 years, glycemic control and lipid profile improved similarly, rates of partial or complete remission of diabetes and hypertension were identical, and quality of life presented a significant improvement for all patients with no inter-group difference.

CONCLUSION

Our results suggest similar short- and long-term outcomes after RYGB for patients ≥ 55 years compared to younger ones; the relative benefit might even be higher for older patients, given their increased comorbidity at baseline.

Racial Disparity in 30-Day Outcomes of Metabolic and Bariatric Surgery

Background

There is evidence of racial disparity in the long-term weight loss outcomes of bariatric surgery. However, there has been a more limited evaluation of the impact of race on immediate perioperative outcomes. The aim of this study was to compare 30-day postoperative outcomes among different races.

Study Design

The 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried to identify patients aged ≥ 18 and body mass index ≥ 35 who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) with known information on race. We then evaluated the effect of five different races on four different 30-day outcomes.

Results

Of the total 106,932 patients (79.5% White, 19.3% African American (AA), 0.5% Asian, 0.4% American Indian or Alaska Native, 0.3% Native Hawaiian or other Pacific Islander), 30-day rates of postoperative complication, readmission, re-intervention, and reoperation were 6, 3.8, 1.3, and 1.2%, respectively. After controlling for other covariates in multivariate logistic regression and selecting White as reference, AA was the only race associated with a higher risk of postoperative complications (odds ratio [OR] 1.13; confidence interval [CI] 1.06–1.2) and readmissions (OR 1.47; CI 1.3–1.6). AA and American Indian or Alaska Native were also associated with higher re-interventions (OR 1.31; CI 1.15–1.51 and OR 2.11; CI 1.03–4.34). Furthermore, AA was associated with lower 30-day reoperations (OR 0.83; CI 0.7–0.9).

Conclusion

This study found significant racial differences in short-term outcomes following bariatric surgery. Factors underlying these disparities are unclear and warrant further investigation.

Missing something? A scoping review of venous thromboembolic events and their associations with bariatric surgery. Refining the evidence base

Background

Venous thromboembolic events (VTE) post-bariatric surgery (BS) lead to morbidity and mortality.

Methods

This scoping review assessed whether reported VTE post-BS could be under/over-estimated; suggested a possible number of VTE post-BS; appraised whether VTE are likely to decrease/increase; examined BS as risk/protective factor for VTE; and mapped the gaps, proposing potential solutions.

Results

VTE appears under-estimated due to: identification/coding of BS and VTE; reporting of exposure (BS); and reporting of outcomes (VTE). The review proposes a hypothetical calculation of VTE post-BS. VTE are unlikely to decrease soon. BS represents risk and protection for VTE. Better appreciation of VTE-BS relationships requires longer-term strategies.

Conclusion

VTE are underestimated. Actions are required for understanding the VTE-BS relationships to in order to crease VTE by better-informed prevention strategy/ies.

Variations in bariatric surgical practice patterns between general and bariatric surgeons: a matched analysis of the 2017 MBSAQIP database

BACKGROUND

While general surgeons (GSs) perform metabolic and bariatric surgery (MABS), these procedures are increasingly performed by metabolic and bariatric surgeons (MBSs). Because MABS is an evolving practice with changing surgical platforms and approaches, it is important to evaluate outcomes between different specialists performing these procedures.

OBJECTIVES

To compare perioperative practice pattern variations and outcomes of MABS performed by GSs versus MBSs.

SETTING

University Hospital, United States.

METHODS

Using the 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we identified Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) cases and stratified them by specialization (GSs versus MBSs). Patient characteristics, practice patterns and outcomes, complications, and 30-day outcomes were compared between cohorts. Matched procedure-specific analyses were performed.

RESULTS

Of 172,430 MABS procedures, 4394 (2.5%) were performed by GSs and 168,036 (97.4%) by MBSs. At baseline, patients of GSs had fewer co-morbidities. GSs more commonly used the robotic platform for SG cases and performed interventions such as staple line reinforcement and staple line check with provocative testing. MBSs more commonly performed robotic (versus laparoscopic) RYGB. Overall complications were low in both study cohorts. After propensity matching, transfusion and venous thromboembolism were higher in SG performed by GSs, while surgical site infection was higher in SG and RYGB performed by MBSs. These findings were not reproduced after case-control matching. In matched analyses, there were no mortality or morbidity differences between study cohorts.

CONCLUSION

MABS is performed safely by both GSs and MBSs, with no difference in morbidity and mortality.

Association of Bariatric Surgery With Risk of Fracture in Patients With Severe Obesity

IMPORTANCE

Given the complex relationship between body mass index, body composition, and bone density and the correlative nature of the studies that have established the prevailing notion that higher body mass indices may be protective against osteopenia and osteoporosis and, therefore, fracture, the absolute risk of fracture in patients with severe obesity who undergo either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) compared with those who do not undergo bariatric surgery is unknown.

OBJECTIVE

To assess the rates of fractures associated with obesity and compare rates between those who do not undergo bariatric surgery, those who undergo RYGB, and those who undergo SG.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective multicenter cohort study of Medicare Standard Analytic Files derived from Medicare parts A and B records from January 2004 to December 2014, patients classified as eligible for bariatric surgery using the US Centers of Medicare & Medicaid criteria who either did not undergo bariatric surgery or underwent RYGB or SG were exactly matched in a 1:1 fashion based on their age, sex, Elixhauser Comorbidity Index, hypertension, smoking status, nonalcoholic fatty liver disease, hyperlipidemia, type 2 diabetes, osteoporosis, osteoarthritis, and obstructive sleep apnea status. Data were analyzed from November to December 2019.

EXPOSURES

RYGB or SG.

MAIN OUTCOMES AND MEASURES

The primary outcome measured in this study was the odds of fracture overall based on exposure to bariatric surgery. Secondary outcomes included the odds of type of fracture (humerus, radius or ulna, pelvis, hip, vertebrae, and total fractures) based on exposure to bariatric surgery.

RESULTS

A total of 49 113 patients were included and were equally made up of 16 371 bariatric surgery-eligible patients who did not undergo weight loss surgery, 16 371 patients who had undergone RYGB, and 16 371 patients who had undergone SG. Each group consisted of an equal number of 4109 men (25.1%) and 12 262 women (74.9%) and had an equal distribution of ages, with 11 780 patients (72.0%) 64 years or younger, 4230 (25.8%) aged 65 to 69 years, 346 (2.1%) aged 70 to 74 years, and 15 (0.1%) aged 75 to 79 years. Patients undergoing RYGB were found to have no significant difference in odds of fractures compared with bariatric surgery-eligible patients who did not undergo surgery. Patients undergoing undergone SG were found to have decreased odds of fractures of the humerus (odds ratio [OR], 0.57; 95% CI, 0.45-0.73), radius or ulna (OR, 0.38; 95% CI, 0.25-0.58), hip (OR, 0.49; 95% CI, 0.33-0.74), pelvis (OR, 0.34; 95% CI, 0.18-0.64), vertebrae (OR, 0.60; 95% CI, 0.48-0.74), or fractures in general (OR, 0.53; 95% CI, 0.46-0.62). Compared with patients undergoing SG, patients undergoing RYGB had a significantly greater risk of total fractures (OR, 1.79; 95% CI, 1.55-2.06) and humeral fractures (OR, 1.60; 95% CI, 1.24-2.07).

CONCLUSIONS AND RELEVANCE

In this cohort study, bariatric surgery was associated with a reduced risk of fracture in bariatric surgery-eligible patients. Sleeve gastrectomy might be the best option for weight loss in patients in which fractures could be a concern, as RYGB may be associated with an increased fracture risk compared with SG.

National Postoperative Bariatric Surgery Outcomes in Patients with Chronic Kidney Disease and End-Stage Kidney Disease

PURPOSE

Obesity is a major risk factor for end-stage kidney disease (ESKD) and is often a barrier to kidney transplantation. However, limited evidence exists evaluating postoperative bariatric surgery outcomes in patients with chronic kidney disease (CKD) and ESKD.

MATERIALS AND METHODS

We performed a retrospective cohort study of patients who underwent bariatric surgery in 2015-2016 using the national Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program dataset. Propensity score matching was used to balance characteristics across patients with CKD and ESKD vs. those without CKD.

RESULTS

There were 323,034 patients without CKD, 1694 patients with CKD, and 925 patients with ESKD who underwent bariatric surgery. Patients with CKD and ESKD had a significantly increased risk of 30-day reoperation (CKD odds ratio [OR] 2.25 95% confidence interval [CI] 1.45-3.51; ESKD OR 3.10, 95% CI 1.72-5.61) and readmission (CKD OR 1.98, 95% CI 1.53-2.56; ESKD OR 2.97, 95% CI 2.05-4.31) compared to patients without CKD; mortality risk was elevated in patients with ESKD (OR 11.59, 95% CI 6.71-20.04) but not in those with CKD (OR 1.00, 95% CI 0.32-3.11). Rates of adverse outcomes were < 15% across all groups. There were 12, 50, and 172 deaths per 1000 person-years among patients without CKD, with CKD, and with ESKD, respectively.

CONCLUSION

Patients with CKD and ESKD experienced higher risk of postbariatric surgery complications compared to those without kidney disease, although absolute complication rates were low across all groups. CKD and ESKD should not be perceived as contraindications to bariatric surgery.

Laparoscopic vertical sleeve gastrectomy, long and short-term impact on weight loss and associated co-morbidities

The laparoscopic vertical sleeve gastrectomy (LVSG) has become the most popular operation for the treatment of morbid obesity in the United States. Being a purely restrictive procedure, the LVSG works to reduce the caloric intake of patients as well as decrease appetite through removal of ghrelin producing cells. Initially developed as the first part of a combined two step restrictive and malabsorptive procedure, the LVSG developed as a standalone procedure when patients lost significant weight with the restrictive portion of the operation alone. Short term outcomes have been promising in terms of weight loss and resolution of comorbid conditions. Long term outcomes are still evolving, but do demonstrate durable weight loss for a significant number of patients. Concerns with the LVSG in the long term revolve around development or worsening of gastroesophageal reflux disease or weight regain. The LVSG has been demonstrated to be a useful tool in the surgical management of morbid obesity.

Mentorship Programs in Bariatric Surgery Reduce Perioperative Complication Rate at Equal Short-Term Outcome-Results from the OPTIMIZE Trial

OBJECTIVES

The aim of this study was to determine the efficacy of coaching on outcome in low volume centers of excellence and to evaluate the influence of mentorship programs on the center development.

BACKGROUND

The number of bariatric procedures has increased steadily in the last years. Providing nationwide bariatric care on a high professional level needs structures to train and guide upcoming centers and ensure high quality in patient care.

METHODS

A prospective multicentered, observational study including laparoscopic sleeve gastrectomies (SG) and Roux-en-Y gastric bypass (RYGB) procedures was performed. Twelve emerging bariatric centers were coached by five experienced bariatric centers. Surgeons of the mentor centers gave guidance on pre- and postsurgical management of their patients including complications and proctored the first interventions. The results were compared regarding operative outcomes, percentage of excess weight loss, complications, and resolution of comorbidities.

RESULTS

A total of 214 of 293 patients (73.0%) completed the study. The most frequently reported complications were wound infection (4.4%), disorder of emptying stomach/new reflux (2.4%), anastomotic leaks, intra-abdominal secondary hemorrhage, and dumping syndrome (2.0% each). The mortality rate was zero. We found no difference in overall complication rates or resolution of obesity-related comorbidities when comparing experienced surgeons with less experienced surgeons.

CONCLUSIONS

Our results suggest that under the conditions of the practices of this study, coaching and mentoring were associated with comparable outcomes both in experienced and emerging centers. In addition, mentorship programs ensure equal outcome quality in terms of improvement of obesity-associated comorbidities.

TRIAL REGISTRATION

NCT Number: NCT01754194 .

Impact of age on morbidity and mortality following bariatric surgery

BACKGROUND

Bariatric surgery is the most effective modality to treat obesity and obesity-related comorbidities. This study sought to utilize the MBASQIP® Data Registry to analyze the impact of age at time of surgery on outcomes following sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) procedures.

METHODS

The MBSAQIP® Data Registry for patients undergoing SG or RYGB procedures between 2015 and 2016 was reviewed. Patients were divided into 4 age groups [18-44; 45-54; 55-64; > 65 years]. Minimal exclusions for revisional and/or emergency surgery were selected and combination variables created to classify complications as major or minor. A comorbidity index was constructed to include diabetes, gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), and prior cardiac surgery. Univariate and multivariate logistic regression analyses were performed to compare age stratifications to the young adult (18-45 years) cohort.

RESULTS

Of 301,605 cases, 279,419 cases (71.2% SG) remained after applying exclusion criteria (79.2% female, mean BMI 45.5 ± 8.1 kg/m², 8.9% insulin-dependent diabetics). Mean age was 44.7 ± 12.0 years (51.3% 18-44 years; 26.9% 45-54 years; 16.3% 55-64 years; 5.5% > 65 years). A univariate analysis demonstrated preoperative differences of lower BMI with increasing age concomitant with increasing frequency of RYGB and a higher comorbidity index (p < 0.0001 vs. 18-45 years). At age > 45 years, major complications and 30-day mortality increased independent of procedure type (p < 0.0001). A multivariate analysis controlling for comorbidity indices demonstrated increasing age (> 45 years) increased risk for major complications and mortality.

CONCLUSION

Overall, bariatric surgery (SG or RYGB) remains a low mortality risk procedure for all age groups. However, all age group classifications > 45 years had higher incidence of major complications and mortality compared to patients 18-45 years (despite older individuals having lower preoperative BMI) indicating delaying surgery is detrimental.

Bariatric Surgery Among Medicare Subgroups: Short- and Long-Term Outcomes

OBJECTIVE

This study sought to examine weight change, postoperative adverse events, and related outcomes of interest among age-qualified (AQ) and disability-qualified (DQ) Medicare recipients compared with non-Medicare (NM) patients undergoing an initial bariatric procedure.

METHODS

The Longitudinal Assessment of Bariatric Surgery (LABS-2) is an observational cohort study of 2,458 adults who underwent Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) bariatric surgery. Weight, percentage body fat, functional status, and comorbidities, as well as postoperative adverse events, were assessed at baseline and annually for 5 years. The 1,943 participants who reported insurance type were categorized into the following groups: AQ, DQ, or NM.

RESULTS

The median preoperative BMI ranged from 45 to 48 kg/m² across groups. For RYGB, 5-year BMI loss was approximately 30% for all groups, and for LAGB, BMI loss was 12% to 15%. Diabetes remission after 5 years was also similar across groups within procedure types (RYGB: 33%-40%; LAGB: 13%-19%). The frequency of adverse events after RYGB ranged from 4.1% for NM participants to 6.7% for DQ participants. After LAGB, there were no adverse events for the AQ group, whereas 3% of DQ participants and 1.8% of NM participants had at least one adverse event.

CONCLUSIONS

Medicare participants experienced substantial BMI loss and diabetes remission, with a frequency of adverse events similar to that of NM participants.

Sleeve Gastrectomy in the Elderly

BACKGROUND

Even though risks are higher and long-term results may be less favorable, the elderly obese can still benefit from bariatric surgery. Whether the higher surgical risk is worth the benefits is yet to be determined.

MATERIALS AND METHODS

We reviewed our database and identified all patients aged 65 or older who underwent sleeve gastrectomy between May 2010 and November 2015. We documented patient demographics, obesity-related comorbidities, body mass index (BMI) before and after the procedure, percent excess weight loss, comorbidity improvement or resolution, length of follow-up, postoperative complications, re-operations, and length of hospital stay. We compared our study group to a control group of sleeve gastrectomy patients under the age of 65.

RESULTS

Sixty-six patients (mean age 67.6 ± 2.6 years) underwent laparoscopic sleeve gastrectomy. Patients achieved an average of 53.5% excess BMI loss (EBMIL) after 21 months of follow-up. EBMIL was inferior to that achieved by the control group (EBMIL 77.3%, p < 0.0001). Elderly patients showed significant improvement or resolution in all obesity-related comorbidities. Complication and re-operation rates were similar between the 2 groups.

CONCLUSION

In an elderly population, laparoscopic sleeve gastrectomy is safe and effective, yet weight loss outcomes are more modest when compared to a younger surgical population. Carefully selected elderly patients can benefit from bariatric surgery.

Incidence and Risk Factors for Mortality Following Bariatric Surgery: a Nationwide Registry Study

BACKGROUND

Although bariatric surgery (BS) is considered safe, concern remains regarding severe post-operative adverse events and mortality. Using a national BS registry, the aim of this study was to assess the incidence, etiologies, and risk factors for mortality following BS.

METHODS

Prospective data from the National Registry of Bariatric Surgery in Israel (NRBS) including age, gender, BMI, comorbidities, and surgical procedure information were collected for all patients who underwent BS in Israel between June 2013 and June 2016. The primary study outcome was the 3.5-year post-BS mortality rate, obtained by cross-referencing with the Israel population registry.

RESULTS

Of the 28,755 patients analyzed (67.3% females, mean age 42.0 ± 12.5 years, and preoperative BMI 42.14 ± 5.21 kg/m²), 76% underwent sleeve gastrectomy (SG), 99.1% of the surgeries were performed laparoscopically, and 50.8% of the surgeries were performed in private medical centers. Overall, 95 deaths occurred during the study period (146.9/100,000 person years). The 30-day rate of post-operative mortality was 0.04% (n = 12). Male gender (HR = 1.94, 95%CI 1.16-3.25), age (HR = 1.06, 95%CI 1.04-1.09), BMI (HR = 1.08, 95%CI 1.05-1.11), and depression (HR = 2.38, 95%CI 1.25-4.52) were independently associated with an increased risk of all-cause 3.5-year mortality, while married status (HR = 0.43, 95%CI 0.26-0.71) was associated with a decreased risk.

CONCLUSION

Mortality after BS is low. Nevertheless, a variety of risk factors including male gender, advanced age, unmarried status, higher BMI, and preoperative depressive disorder were associated with higher mortality rates. Special attention should be given to these "at-risk" BS patients.

Bariatric peri-operative outcomes are affected by annual procedure-specific surgeon volume

BACKGROUND

There is limited data examining specific annual surgeon procedural volumes associated with improvement of postoperative outcomes following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).

OBJECTIVES

Effect of surgeon volume on procedural outcomes.

METHODS

Using the SPARCS Administrative database, patients undergoing laparoscopic RYGB or SG between 2010-2014 were analyzed. Multivariable generalized linear mixed regression models were first used to analyze the influences of 3 yearly mean volumes (combined, RYGB and SG mean volumes) on each of three surgical outcomes: 30-day readmission, peri-operative complications, and extended length of stay (LOS), while accounting for patient specific variables.

RESULTS

A total of 46,511 laparoscopic bariatric procedures were included in the study. Risk for any complication and 30-day readmissions following RYGB decreased with increasing RYGB volume up to a specific volume and stayed similar afterward (OR 0.97, 95% CI 0.96-0.98 while volume < 247.9 cases/year and OR 0.99, 95% CI 0.98-0.99 while volume < 354.1 cases/year, respectively) while risk for extended LOS decreased with increasing combined bariatric mean volume up to a specific volume and stayed similar afterward (OR 0.9, 95% CI 0.85-0.95 while volume < 62.1 cases/year). Similar patterns were found for extended LOS and complications following SG (OR 0.82, 95% CI 0.72-0.93 while SG volume < 26.3 cases/year and OR 0.94, 95% CI 0.91-0.98 while combined volume < 62.1 cases/year, respectively), while 30-day readmission following SG significantly increased when combined bariatric volume being more than 138 cases/year (OR 1.10, 95% CI 1.00-1.21 while combined volume > 138 cases/year)).

CONCLUSIONS

Bariatric procedure peri-operative outcomes are affected by procedure-specific annual surgeons' volume.

Malnutrition in obesity before and after bariatric surgery

Bariatric surgeries are considered the only effective way of weight loss therapy in morbidly obese patients, i.e. body mass index ≥ 35. However, micronutrient deficiencies and malnutrition are common after most bariatric procedures and thus, pre- and postoperative nutritional assessment and corrections are advised. The present review is presented in an effort to describe in some detail about prevalence, and mechanisms of macro- and micronutrient deficiencies in obese and post-bariatric surgery individuals. We also aimed to summarize the data on screening and supplementation of macro- and micronutrients before and after bariatric surgeries.

Safety of bariatric surgery in patients older than 65 years

BACKGROUND

The increase in life expectancy along with the obesity epidemic has led to an increase in the number of older patients undergoing bariatric surgery. There is conflicting evidence regarding the safety of performing bariatric procedures on older patients.

OBJECTIVE

The purpose of this study was to compare the safety of laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for older patients (>65 yr).

SETTING

Nationwide analysis of accredited centers.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2017 database was used to identify nonrevisional laparoscopic RYGB and SG procedures. Comparisons were made based on patient age. Clinical outcomes included postoperative events and mortality.

RESULTS

There was a total 13,422 and 5395 matched pairs for SG and RYGB in comparing patients aged 18 years to those aged 65 and >65 years, respectively, and 5395 matched RYGB and SG procedures performed in patients >65 years. The complication rate was higher in older patients undergoing RYGB compared with SG (risk difference = 2.39%, 95% confidence interval: 1.57%-3.21%, P < .0001). When comparing older to younger patients, the older group had a higher complication rate for SG but not for RYGB (SG: risk difference = 1.01%, 95% confidence interval: .59%-1.43%, P < .0001, RYGB: risk difference = .59%, 95% confidence interval: -.29% to 1.47%, P = .2003).

CONCLUSIONS

Overall complication rates of bariatric surgery are low in patients >65 years. SG appears to have a favorable safety profile in this patient population compared with RYGB. The overall complication rate for RYGB is not significantly different between the older and younger groups.

30-Day Outcomes After Intraoperative Leak Testing for Bariatric Surgery Patients

BACKGROUND

Intraoperative testing of anastomoses and staples lines is commonly performed to minimize the risk of postoperative leaks in bariatric surgery, but its impact is unclear. The aim of this study was to determine the association between leak testing and 30-d postoperative leak, bleed, reoperation, and readmission rates for patients undergoing laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB).

METHODS

This is a retrospective observational study utilizing 2015-2016 data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Postoperative outcomes were compared using χ² test. Multivariable logistic regression was used to identify factors associated with 30-d outcomes.

RESULTS

We included 237,081 patients. Leak testing was performed on 73.0% and 92.1% of LSG and RYGB patients, respectively. LSG was associated with lower rates of leak, bleed, reoperation, and readmission than RYGB. On multivariable analysis, intraoperative leak testing was associated with increased rates of postoperative leak for LSG and RYGB (OR 1.48 and 1.90, respectively) and lower rates of bleed for LSG (OR 0.76). There were no significant associations between leak testing and rates of reoperation or readmission.

CONCLUSIONS

Use of intraoperative leak testing was not associated with improved outcomes for either LSG or RYGB. A prospective trial investigating leak testing is warranted to better elucidate its impact.

Bariatric Procedures in Older Adults in the United States: Analysis of a Multicenter Database

Background: Bariatric procedures help reduce obesity-related comorbidities and thus improve survival. Clinical characteristics and outcomes after bariatric procedures in older adults were investigated. Methods: A multi-institutional Nationwide Inpatient Sample (NIS) database was queried from years 2005 through 2012. Older adults >60 years of age with procedure codes for bariatric procedures and a diagnosis of obesity/morbid obesity were selected to compare clinical characteristics/outcomes between those undergoing closed versus open procedures and identify risk factors associated with in-hospital mortality and increased hospital length of stay (LOS). Results: Over the study period, 79,122 bariatric procedures were performed. Those undergoing open procedures compared to closed procedures had a higher in-hospital mortality (0.8% vs. 0.2%) and a longer hospital LOS (4.8 days vs. 2.2 days). Risk factors significantly associated with in-hospital mortality were open procedures, the Western region, and the Elixhauser comorbidity index. Risk factors associated with increased LOS were Medicaid insurance type, an open procedure, a higher Elixhauser comorbidity score, a required skilled nursing facility (SNF) discharge, and died in hospital. Conclusion: Closed bariatric procedures are increasingly being preferred in older adults, with a four-fold lower mortality compared to open procedures. Besides choice of procedure, the presence of specific comorbidities is associated with increased mortality in older adults.

Treatment of obesity in older persons-A systematic review

The study aims to systematically review the available evidence regarding weight loss interventions (lifestyle, surgical, and pharmacological) for obesity in adults aged over 60 years. A search of prospective, randomized studies took place in January 2018, on Medline (Web of Science) and PubMed databases. Search terms included the following: elderly, obese, hypocaloric, pharmacotherapy, and bariatric surgery. Abstracts were screened for eligibility. A total of 256 publications regarding lifestyle interventions were identified; of these, 69 studies were eligible. As no eligible studies were identified for pharmacotherapy or bariatric surgery, the search was broadened to include non- randomized studies. Four pharmacotherapy and 66 surgery studies were included. Lifestyle intervention had similar weight loss efficacy in older compared with younger people, with positive effects on a number of relevant outcomes, including physical function and cardiovascular parameters. There was little data regarding obesity pharmacotherapy in older persons. The available data for bariatric surgery indicate comparable weight loss and resolution of type 2 diabetes, with similar or slightly higher complication rates in older compared with younger people. Older age alone should not be considered a contraindication to intensive lifestyle or surgical intervention for obesity. There are insufficient data to guide clinical decisions regarding obesity pharmacotherapy in older people.

Randomized clinical trial of an enhanced recovery after surgery programme versus conventional care in laparoscopic Roux-en-Y gastric bypass surgery

Background

Enhanced recovery after surgery (ERAS) programmes have led to a decreased duration of hospital stay in several surgical fields, but have not been fully tested in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) for obesity. This study aimed to investigate an ERAS programme versus standard care in these patients.

Methods

Between January 2013 and July 2014, patients undergoing LRYGB were randomized to ERAS or conventional care. The primary outcome was functional hospital stay, defined as the time between end of surgery and when predefined discharge criteria (pain adequately controlled, fever and postoperative nausea and vomiting (PONV) absent, full liquid diet tolerated, mobilized and feeling fit for discharge) were met. Secondary outcomes were total length of hospital stay, 30-day complication and mortality rates, duration of surgery, time spent on the recovery ward and health-related quality of life.

Results

A total 220 patients were randomized to ERAS (110 patients) or conventional (110) care. Patients in the ERAS group had shorter functional hospital stay (17·4 versus 20·5 h; P < 0·001), quicker pain control, tolerated liquid diet earlier, had earlier control of PONV, mobilized sooner and were comfortable with discharge sooner than those receiving conventional care. Total length of hospital stay, duration of surgery, time spent on the recovery ward, health-related quality of life, complication and readmission rates did not differ between the study groups. There were no deaths.

Conclusion

Patients under ERAS care recovered faster after LRYGB surgery than those receiving conventional care, with no increase in readmission and postoperative morbidity rates. Registration number: NTR3853 (http://www.trialregister.nl/).

Preoperative functional health status is a predictor of short-term postoperative morbidity and mortality after bariatric surgery

BACKGROUND

Functional health status (FHS) is the ability to perform activities of daily living without caregiver assistance.

OBJECTIVES

The primary aim of this study was to determine the impact of impaired preoperative FHS on morbidity and mortality within 30 days of bariatric surgery.

SETTING

Academic medical center in the United States.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 data set was queried for primary minimally invasive bariatric procedures. The demographic characteristics and perioperative details of patients who were functionally independent were compared with patients with impaired FHS. Multivariable logistic regression analysis was performed to determine the odds of developing a perioperative complication or death for patients with impaired functional health.

RESULTS

Of patients, 1515 (1.0%) were reported as having impaired FHS and 147,195 patients (99.0%) were independent before surgery. Patients with impaired FHS experienced significantly longer length of hospital stays (2.4 versus 1.8 d; P < .0001), a higher morbidity (adjusted odds ratio 1.5; P <0.0001), and higher mortality (adjusted odds ratio 2.1; P < .0001). Impaired FHS resulted in significantly increased rate of unplanned admissions to the intensive care unit, interventions, reoperations, and readmissions within 30 days of surgery.

CONCLUSIONS

Patients with impaired FHS preoperatively have a significantly increased risk of short-term morbidity and mortality after bariatric surgery. The results of this study highlight the importance of establishing quality initiatives focused on improving short-term outcomes for patients with impaired functional health status.

Laparoscopic Weight Loss Surgery in the Elderly: An ACS NSQIP Study on the Effect of Age on Outcomes

In an era of rising obesity and an aging population, there are conflicting data regarding outcomes of laparoscopic weight loss surgery in older Americans. The aim of this study was to characterize the short-term outcomes of laparoscopic weight loss surgery in the elderly. The ACS NSQIP database was queried for obese patients aged ≥40 years undergoing laparoscopic Roux-en-Y gastric bypass or sleeve gastrectomy. Patients were subdivided into age groups: 40 to 49, 50 to 59, 60 to 64, 65 to 69, and ≥70 years, and compared with univariate and multivariate analyses. Fifty-three thousand five hundred thirty-three patients were identified. Roux-en-Y gastric bypass was performed in 57.5 per cent of cases and was more common than sleeve gastrectomy in all age groups ( P < 0.05). Comorbidities increased significantly with increasing age. There was an increase in minor (4.6% vs 9.1%; P < 0.0001) and major complications (2.2% vs 6.3%; P < 0.0001), and 30-day mortality (0.1% vs 0.5%; P = 0.0001) between the 40 to 49 and ≥70 years age groups. Increased age was independently associated with major complications. Mortality also increased with age. Older patients undergoing laparoscopic weight loss surgery have increased morbidity and mortality. When controlling for comorbidities, increases in age continued to impact major and minor complications and mortality.

Neuropsychological Functioning in Older Adults with Obesity: Implications for Bariatric Surgery

Bariatric surgery is the most effective approach to treating morbid obesity, resulting in decreased morbidity, mortality, and improved quality of life. Research on outcomes has generally been restricted to young and middle-aged adults, despite a growing epidemic of obesity in older adults. The use of bariatric surgery has been limited in older individuals, in part due to concerns that preexisting cognitive dysfunction increases the risk of poor post-surgical outcomes, including cognitive decline. The literature on the relationship between obesity and cognition in older adults is emerging, but fraught by several methodological limitations. While there is insufficient research to determine the nature of cognitive outcomes following bariatric surgery in older adults, the aim of this paper is to review the existing evidence and make the case for further study.

Perioperative complications of sleeve gastrectomy: Review of the literature

Sleeve gastrectomy (SG) has known a spectacular rise worldwide during the last decade. The absence of digestive anastomosis simplifies the surgical technique, reducing anastomosis-related complications such as fistula, stricture and marginal ulcer. Furthermore, the respect for digestive continuity preserves the functions of pylorus, that regulates gastric emptying, and duodenum, where calcium, B vitamins and iron are absorbed. Despite the multiple advantages, SG also has specific complications such as bleeding, stenosis, portal thrombosis and leak. The staple line leak at the oesophagogastric junction is the most feared complication and its prevention remains difficult, as the involved mechanisms have been only partially elucidated. Its management is long and requires a multidisciplinary technical platform including Intensive Care Unit, digestive endoscopy and interventional radiology as well as a specialised surgeon. The aim of this review is to explain in detail the perioperative complications of SG, their prevention and treatment, referring to the most recent available literature.

Operative morbidity of laparoscopic sleeve gastrectomy in subjects older than age 65

BACKGROUND

Continuous developments in healthcare have led to an increase in average life expectancy. Obesity in aged persons is increasing and is more clearly associated with an increased risk of diabetes, cardiovascular disease, lipid abnormalities, mobility-limited problems, and other co-morbidities in this category of age.

OBJECTIVES

The aim of the present study was to report the outcomes of laparoscopic sleeve gastrectomy in patients >65 years of age.

SETTING

Private hospital, France.

METHODS

A retrospective review was performed from patients aged >65 years who had undergone laparoscopic sleeve gastrectomy (June 2011-December 2017). The data analyzed included age, co-morbidities, preoperative body mass index, length of hospital stay, and postoperative complications.

RESULTS

A total of 93 patients were included with a mean age of 68.8 years (range, 65-78); 73 were female (78.5 %), and the mean preoperative body mass index was 43.6 ± 5.4 kg/m². Revisional surgery was well represented in 34.4% of cases. Thirty-two patients had a previous gastric band converted to laparoscopic sleeve gastrectomy, with 12 cases of 1-step revision (37.5%). Eleven patients (11.8%) had concomitant cholecystectomy. All procedures were performed laparoscopically with no peroperative complications. The median hospital stay was 3.1 days (1-6 d). Complications included 1 hematoma treated conservatively. The 30-day mortality rate was 0%. The mean excess weight loss at 1 year postoperatively was 67.1% (range, 34%-107%) with a follow-up rate of 78.1%. Resolution or improvement was observed in 65% of patients presenting with diabetes, in 72.5% of patients presenting with HTA, in 47.1% of patients presenting with dyslipidemia, and in 63.6% of patients presenting with sleep apnea.

CONCLUSIONS

Sleeve gastrectomy in elderly patients seems to be safe in terms of complications. Surgery is associated with a low-morbidity profile. Sleeve gastrectomy is our preferred procedure in this category of patients.

Midterm outcomes of sleeve gastrectomy in the elderly

BACKGROUND

The increase in life expectancy presents health systems with a growing challenge in the form of elderly obesity. Bariatric surgery has been shown to be a safe and effective treatment for obesity with reduction of excess weight and improvement in obesity-related co-morbidities. However, only recently have surgeons begun performing these operations on elderly patients on a larger scale, making data regarding mid- and long-term outcomes scarce. The objective of this study was to evaluate the safety and midterm efficacy of laparoscopic sleeve gastrectomy (LSG) in patients aged ≥60 years.

METHODS

All patients aged ≥60 years who underwent LSG between 2008 and 2014 and achieved ≥24-month follow-up were retrospectively reviewed. Demographic characteristics and perioperative data were analyzed. Weight loss parameters and co-morbidity resolution rates were compared with preoperative data.

RESULTS

In total 55 patients aged ≥60 years underwent LSG. Mean patient age was 63.9 ± 3.2 years (range, 60-75.2), and mean preoperative body mass index was 43 ± 6.0 kg/m². Perioperative morbidity included 5 cases of hemorrhage necessitating operative exploration, 2 cases of reduced hemoglobin levels treated with blood transfusion, and 1 case of portal vein thrombosis managed with anticoagulation. There were no mortalities. Mean follow-up time was 48.6 (range, 25.6-94.5) months. Mean percentage of excess weight loss was 66.4 ± 19.7, 67.5 ±1 6.4, 61.4 ± 18.3, 66.7 ± 25.6, 50.7 ± 21.4 at 12, 24, 36, 37 to 60, and 61 to 96 months, respectively. Statistically significant improvement of type 2 diabetes, hypertension, and dyslipidemia were observed at the latest follow-up (P < .01).

CONCLUSION

LSG offers an effective treatment of obesity and its co-morbidities in patients aged ≥60 years, albeit with a high perioperative bleeding rate at our center; efficacy is maintained for at least 4.5 years.

Transient receptor potential (TRP) channels: a metabolic TR(i)P to obesity prevention and therapy

Cellular transport of ions, especially by ion channels, regulates physiological function. The transient receptor potential (TRP) channels, with 30 identified so far, are cation channels with high calcium permeability. These ion channels are present in metabolically active tissues including adipose tissue, liver, gastrointestinal tract, brain (hypothalamus), pancreas and skeletal muscle, which suggests a potential role in metabolic disorders including obesity. TRP channels have potentially important roles in adipogenesis, obesity development and its prevention and therapy because of their physiological properties including calcium permeability, thermosensation and taste perception, involvement in cell metabolic signalling and hormone release. This wide range of actions means that organ-specific actions are unlikely, thus increasing the possibility of adverse effects. Delineation of responses to TRP channels has been limited by the poor selectivity of available agonists and antagonists. Food constituents that can modulate TRP channels are of interest in controlling metabolic status. TRP vanilloid 1 channels modulated by capsaicin have been the most studied, suggesting that this may be the first target for effective pharmacological modulation in obesity. This review shows that most of the TRP channels are potential targets to reduce metabolic disorders through a range of mechanisms.

Outcome of bariatric surgery in older patients

BACKGROUND

People are living longer than they were expected to 2 decades ago. Increased life expectancy and reduced mortality encompasses a simultaneous increase in the number of older adults with obesity that entails an increase of co-morbidities, such as diabetes, hypertension, cancer, and many other diseases. The aim of our study was to compare the outcomes of bariatric surgery in patients age ≥65 in comparison with younger patients.

METHODS

This retrospective study compares bariatric surgeries performed in a private institution between the years 2013 and 2015. The study included 9044 patients divided into an older group (451 patients) and the younger group (8593 patients).

RESULTS

In the younger group, bariatric surgery is distributed as follows: 77.68% sleeve gastrectomy, 12.72% gastric banding, 9.27% gastric bypass, and .33% duodenal switch or biliopancreatic diversion; in the older group: 70.51% sleeve gastrectomy, 15.08% gastric bypass, 13.97% gastric band, and .44% biliopancreatic diversion. In the control group 550 cases (6.4%) underwent revisional surgery; 64 cases (14.10%) underwent revision in the older group. Older patients lost less excess weight than younger patients (72.44% versus 86.11%, respectively). Older patients presented higher rates of complications (8.42% versus 5.59%), co-morbidities (77.60% versus 55.45%), and revisions (1.33% versus .77%). There was no statistical difference in hospital stay between older group and control group (2.27 versus 2.23, respectively). When performing a Clavien-Dindo classification, we demonstrated significant differences in class 3B and 4A and no differences in other classes. Two deaths occurred in the control group. Diabetes, fatty liver, and sleep apnea have been improved or remitted in >90% of patients in both groups, hypertension and hyperlipidemia by >80%, and hyperuricemia and ischemic heart disease were improved or resolved in >70% of the patients CONCLUSIONS: Bariatric surgery in the elderly has more complications, but it can still be considered safe.